Nearly 5 million American women underwent hysterectomy in the
last decade, making this procedure one of the most frequently
performed operations for women of reproductive age (1) and an
important public health concern. Since 1970, CDC has provided
epidemiologic surveillance of hysterectomies performed on women
15-44 years of age; summary data have been previously published
(2-4). This report provides an analysis of the influence of age,
race, geographic region, and surgical approach on hysterectomy
rates for 1981-1982 and updates the analysis of hysterectomy
rates for 1970-1980 (4). This previous analysis showed that the
nationwide hysterectomy rate declined from 1975 to 1980 among
women of reproductive age. The current analysis, however,
indicates that the noted decline may have begun to plateau,
although rates in 1982 were the lowest since 1970. Major
differences in rates by region and age and in the percentage of
hysterectomies performed by the vaginal route have persisted. In
1982, for the first time since surveillance began in 1970, blacks
had a lower hysterectomy rate than whites.
Methods

The methods of this study have been described in detail
elsewhere (2). In brief, the data were collected by the National
Center for Health Statistics (NCHS) as part of the ongoing
National Hospital Discharge Survey (NHDS), which estimates the
number and characteristics of patients admitted to U.S.
non-Federal, short-stay hospitals for surgical procedures,
disease, or injury. For this and previous reports, only total
and subtotal hysterectomies with or without concomitant
oophorectomy were included; radical hysterectomies and pelvic
exenteration were excluded.

The population estimates used in computing rates for this
report were based on data from current population surveys
conducted by the U.S. Bureau of the Census. Data on race were
grouped into the categories of white and black, the latter
category including all races other than white. In 1981, NCHS did
not report the percentage of hysterectomies classified as unknown
for race. Prior to release of data, unknowns were redistributed
between the categories of white and black based on the
distribution of race in the geographic area of the hospital and
on information on the diagnoses and expected source of payment
indicated on those records for which race was reported (5). This
was not done for the 1982 data. In 1982, as for all previous
years except 1981, CDC redistributed the 9% of hysterectomies
classified as unknown for race according to the percentage of
knowns for race in that year (2-4).
Results

In the period 1970-1982, an estimated 5,170,000 women 15-44
years of age underwent hysterectomy in U.S. non-Federal,
short-stay hospitals. The number of hysterectomies increased
from a low of 306,000 in 1970 to a high of 442,000 in 1977 and
then declined to 421,000 in 1981 and 407,000 in 1982 (Figure 1).

The hysterectomy rate in 1981 was 7.9/1,000 women ages 15-44
years and in 1982 was 7.5, the lowest rate since 1970 (Figure 2).
From 1970 to 1981, the hysterectomy rate for black women was
higher than that for white women. However, in 1982, for the
first time since surveillance began in 1970, the rate for black
women, 6.7/1,000, was less than the 7.7 rate for white women.
From 1975 to 1982, the hysterectomy rate declined 14% for whites
and 34% for blacks. In the period 1981-1982, the average age at
the time of hysterectomy was 35 years for both blacks and whites.

For the period 1981-1982, as in previous years, the highest
hysterectomy rate for women of reproductive age was for the 35-
to 44-year age group, and the lowest was for the 15- to 24-year
age group (Figure 3). In 1982, approximately one in 63 women
35-44 years of age underwent a hysterectomy. This is a
conservative estimate because women who had had hysterectomies in
previous years were not removed from the denominator.

Hysterectomy rates also varied by region during this period
(Figure 4). As in previous years, women in the Northeast had the
lowest hysterectomy rate of the four regions, whereas women in
the South had the highest rate. The hysterectomy rate for women
in the South was 2.5 times that for women in the Northeast. The
average age at time of hysterectomy was similar in all geographic
areas, ranging from 34.2 years in the South to 36.6 years in the
Northeast.

In 1981 and 1982, 27% and 24%, respectively, of all
hysterectomies were performed by the vaginal route (Figure 5).
In 1970, the percentage of vaginal hysterectomies among whites
(27%) was similar to that among blacks (25%). By 1982, however,
the percentage among whites (26%) was twice that among blacks
(13%). In the period 1981-1982, there were substantial
differences in the percentage of vaginal hysterectomies by
region: 14% in the Northeast, 23% in the North Central region,
27% in the South, and 33% in the West.
Discussion

Analysis of NHDS data on hysterectomy among women of
reproductive age shows that the decline in the nationwide rate
noted from 1975 to 1980 may have begun to plateau in the period
1981-1982. However, since the rates for 1981 and 1982 represent
only two annual estimates among the 13 annual estimates that have
now been reported, it cannot be ascertained if these new
estimates represent the beginning of a plateau in rates or a
continuation of the previously noted decline.

These results probably underestimate the true rates of
hysterectomy because women undergoing hysterectomy in Federally
operated hospitals are not included in the NHDS data, and women
ages 15-44 years who had already had a hysterectomy were not
excluded from the denominator. The degree to which these rates
are underestimated is probably greater in those areas and for
those ages that had relatively higher rates of hysterectomy.
However, a study that adjusted the 1971-1978 hysterectomy rates
for the number of U.S. women ages 15-44 years who had already had
a hysterectomy showed that trends in rates were similar to those
reported for this period in previous CDC surgical sterilization
surveillance reports (6).

During 1979-1980, differences in hysterectomy rates between
blacks and whites declined noticeably. In 1981, however, the
rates of blacks and whites diverged, only to converge again in
1982. The instability of race-specific rates may be due, in
part, to the two different methods of imputing unknowns for race
in 1981 and 1982. Similarly, the divergence in percentages of
vaginal hysterectomies between blacks and whites that was seen in
the period 1981-1982 may be due to unstable race-specific
hysterectomy rates, which, in turn, may be due either to the
different methods of redistributing unknowns for race or to the
small absolute number of hysterectomies among blacks surveyed.

Variations in hysterectomy rates by region have persisted since
1970 (2-4). Factors related to both patients and physicians may
contribute to these regional differences. Patient-related
factors may include regional differences in the incidence of
gynecologic conditions and in general attitudes toward surgery or
sterilization during the reproductive years (7).
Physician-related factors may include regional differences in
trends in training and practice (8,9).

In conclusion, while 1982 national and regional hysterectomy
rates reached their lowest level since 1970, those for the period
1981-1982 may represent either the beginning of a plateau or a
continued decline in rates since 1975. Further surveillance of
hysterectomy rates among women of reproductive age in U.S.
non-Federal, short-stay hospitals will determine the direction of
these trends in the early 1980s.

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